An independent investigation into the care and treatment of Mr J: Published March 2025

We have referred to potential improvements in the formulation of an individual’s difficulties, care planning and risk assessment to clarify the understanding of complex cases. The Trust develop a care panning process which provides greater emphasis on a longitudinal perspective, … Read more We have referred to potential improvements in the formulation of an individual’s difficulties, care planning and risk assessment to clarify the understanding of complex cases. The Trust develop a care panning process which provides greater emphasis on a longitudinal perspective, more curiosity regarding the full range of factors influencing behaviour, and risk summaries that are updated and lend themselves more easily to safety planning approaches. Show less

This investigation highlights some of the problems associated with teams working independently from each other, with the potential for individuals with complex difficulties to fall outside of service criteria, or to be excluded from some service provision. The Trust should … Read more This investigation highlights some of the problems associated with teams working independently from each other, with the potential for individuals with complex difficulties to fall outside of service criteria, or to be excluded from some service provision. The Trust should ensure a pathway of care that promotes joint working between teams and a shared understanding of patients which will help to reduce this area of risk. Show less

The Trust should ensure a greater degree of proactive planning, informed by dynamic risk assessment and care planning, to manage complex cases in the community.

The Trust should ensure a more proactive approach to family involvement in the care of patients with psychosis which could improve care planning and enhance support to patients and their families.